401k Plan data: EXCELSIOR WELLNESS 403(B) PLAN plan

EXCELSIOR WELLNESS 403(B) PLAN 401k Plan overview

Plan Name	EXCELSIOR WELLNESS 403(B) PLAN
Plan identification number	002

EXCELSIOR WELLNESS 403(B) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

EXCELSIOR WELLNESS has sponsored the creation of one or more 401k plans.

Company Name: EXCELSIOR WELLNESS

Employer identification number (EIN): 911189908

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about EXCELSIOR WELLNESS

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 1982-10-01

Company Identification Number: 601138592

Legal Registered Office Address: 601 W MAIN AVE STE 1400

SPOKANE
United States of America (USA)
992010635

More information about EXCELSIOR WELLNESS

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EXCELSIOR WELLNESS 403(B) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01 JOSH MARTIN 2023-12-06
002 2021-01-01 JOSH MARTIN 2022-10-17
002 2020-01-01 JOSH MARTIN 2021-10-13
002 2019-01-01 JOSH MARTIN 2020-10-13
002 2018-01-01 JOSH MARTIN 2019-10-10
002 2017-01-01
002 2016-01-01
002 2015-01-01 KIMBERLY PIERONI 2016-06-16

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
002	2022-01-01	JOSH MARTIN	2023-12-06
002	2021-01-01	JOSH MARTIN	2022-10-17
002	2020-01-01	JOSH MARTIN	2021-10-13
002	2019-01-01	JOSH MARTIN	2020-10-13
002	2018-01-01	JOSH MARTIN	2019-10-10
002	2017-01-01
002	2016-01-01
002	2015-01-01	KIMBERLY PIERONI	2016-06-16

Plan Statistics for EXCELSIOR WELLNESS 403(B) PLAN

401k plan membership statisitcs for EXCELSIOR WELLNESS 403(B) PLAN

Measure Date Value
2022: EXCELSIOR WELLNESS 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 250
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 197
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 72
Total of all active and inactive participants 2022-01-01 269
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 269
Number of participants with account balances 2022-01-01 218
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: EXCELSIOR WELLNESS 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 220
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 182
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 68
Total of all active and inactive participants 2021-01-01 250
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 250
Number of participants with account balances 2021-01-01 201
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: EXCELSIOR WELLNESS 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 173
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 173
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 47
Total of all active and inactive participants 2020-01-01 220
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 220
Number of participants with account balances 2020-01-01 167
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: EXCELSIOR WELLNESS 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 173
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 173
Number of participants with account balances 2019-01-01 156
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: EXCELSIOR WELLNESS 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 177
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 155
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 31
Total of all active and inactive participants 2018-01-01 186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 186
Number of participants with account balances 2018-01-01 149
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: EXCELSIOR WELLNESS 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 154
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 23
Total of all active and inactive participants 2017-01-01 177
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 177
Number of participants with account balances 2017-01-01 136
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: EXCELSIOR WELLNESS 403(B) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 120
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 174
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 7
Total of all active and inactive participants 2016-01-01 181
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 181
Number of participants with account balances 2016-01-01 107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0

Measure	Date	Value
2022: EXCELSIOR WELLNESS 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	250
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	197
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	72
Total of all active and inactive participants	2022-01-01	269
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	269
Number of participants with account balances	2022-01-01	218
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: EXCELSIOR WELLNESS 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	220
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	182
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	68
Total of all active and inactive participants	2021-01-01	250
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	250
Number of participants with account balances	2021-01-01	201
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: EXCELSIOR WELLNESS 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	173
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	173
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	47
Total of all active and inactive participants	2020-01-01	220
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	220
Number of participants with account balances	2020-01-01	167
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: EXCELSIOR WELLNESS 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	173
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	173
Number of participants with account balances	2019-01-01	156
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: EXCELSIOR WELLNESS 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	177
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	155
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	31
Total of all active and inactive participants	2018-01-01	186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	186
Number of participants with account balances	2018-01-01	149
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: EXCELSIOR WELLNESS 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	154
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	23
Total of all active and inactive participants	2017-01-01	177
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	177
Number of participants with account balances	2017-01-01	136
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: EXCELSIOR WELLNESS 403(B) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	120
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	174
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	7
Total of all active and inactive participants	2016-01-01	181
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	181
Number of participants with account balances	2016-01-01	107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0

Financial Data on EXCELSIOR WELLNESS 403(B) PLAN

Measure	Date	Value
2022 : EXCELSIOR WELLNESS 403(B) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$238
Total income from all sources (including contributions)	2022-12-31	$293,444
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$215,039
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$211,230
Expenses. Certain deemed distributions of participant loans	2022-12-31	$214
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$788,931
Value of total assets at end of year	2022-12-31	$3,010,274
Value of total assets at beginning of year	2022-12-31	$2,932,107
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$3,595
Total interest from all sources	2022-12-31	$1,860
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$414,423
Participant contributions at end of year	2022-12-31	$34,936
Participant contributions at beginning of year	2022-12-31	$30,574
Participant contributions at end of year	2022-12-31	$0
Participant contributions at beginning of year	2022-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$181,610
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$238
Other income not declared elsewhere	2022-12-31	$700
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$78,405
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$3,010,274
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$2,931,869
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$2,927,304
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$2,851,533
Value of interest in pooled separate accounts at end of year	2022-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$0
Interest on participant loans	2022-12-31	$1,860
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-498,047
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$192,898
Employer contributions (assets) at end of year	2022-12-31	$48,034
Employer contributions (assets) at beginning of year	2022-12-31	$50,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$211,230
Contract administrator fees	2022-12-31	$3,595
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2022-12-31	450250958
2021 : EXCELSIOR WELLNESS 403(B) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$238
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$848,857
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$166,113
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$162,413
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$464,034
Value of total assets at end of year	2021-12-31	$2,932,107
Value of total assets at beginning of year	2021-12-31	$2,249,125
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$3,700
Total interest from all sources	2021-12-31	$1,137
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$339,471
Participant contributions at end of year	2021-12-31	$30,574
Participant contributions at beginning of year	2021-12-31	$14,821
Participant contributions at end of year	2021-12-31	$0
Participant contributions at beginning of year	2021-12-31	$75
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$74,563
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$238
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2021-12-31	$0
Other income not declared elsewhere	2021-12-31	$64
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$682,744
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$2,931,869
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$2,249,125
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$2,851,533
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$1,971,914
Value of interest in pooled separate accounts at end of year	2021-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$212,432
Income. Interest from loans (other than to participants)	2021-12-31	$1,137
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$383,622
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$50,000
Employer contributions (assets) at end of year	2021-12-31	$50,000
Employer contributions (assets) at beginning of year	2021-12-31	$49,883
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$162,413
Contract administrator fees	2021-12-31	$3,700
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2021-12-31	450250958
2020 : EXCELSIOR WELLNESS 403(B) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$751,962
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$85,135
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$80,583
Expenses. Certain deemed distributions of participant loans	2020-12-31	$1,108
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$437,683
Value of total assets at end of year	2020-12-31	$2,249,125
Value of total assets at beginning of year	2020-12-31	$1,582,298
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$3,444
Total interest from all sources	2020-12-31	$890
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$260,843
Participant contributions at end of year	2020-12-31	$14,821
Participant contributions at beginning of year	2020-12-31	$13,013
Participant contributions at end of year	2020-12-31	$75
Participant contributions at beginning of year	2020-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$126,883
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$666,827
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$2,249,125
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$1,582,298
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$1,971,914
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$1,382,709
Value of interest in pooled separate accounts at end of year	2020-12-31	$212,432
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$186,576
Interest on participant loans	2020-12-31	$890
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$313,389
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$49,957
Employer contributions (assets) at end of year	2020-12-31	$49,883
Employer contributions (assets) at beginning of year	2020-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$80,583
Contract administrator fees	2020-12-31	$3,444
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Unqualified
Accountancy firm name	2020-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2020-12-31	450250958
2019 : EXCELSIOR WELLNESS 403(B) PLAN 2019 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2019-12-31	$53
Total unrealized appreciation/depreciation of assets	2019-12-31	$53
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$448,524
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$76,181
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$73,371
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$185,122
Value of total assets at end of year	2019-12-31	$1,582,298
Value of total assets at beginning of year	2019-12-31	$1,209,955
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$2,810
Total interest from all sources	2019-12-31	$948
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$100,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$184,131
Participant contributions at end of year	2019-12-31	$13,013
Participant contributions at beginning of year	2019-12-31	$12,209
Participant contributions at end of year	2019-12-31	$0
Participant contributions at beginning of year	2019-12-31	$75
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$991
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$372,343
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$1,582,298
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$1,209,955
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Investment advisory and management fees	2019-12-31	$2,810
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$1,382,709
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$996,114
Value of interest in pooled separate accounts at end of year	2019-12-31	$186,576
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$151,845
Interest on participant loans	2019-12-31	$948
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$262,401
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$0
Employer contributions (assets) at end of year	2019-12-31	$0
Employer contributions (assets) at beginning of year	2019-12-31	$49,712
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$73,371
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2019-12-31	450250958
2018 : EXCELSIOR WELLNESS 403(B) PLAN 2018 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2018-12-31	$437
Total unrealized appreciation/depreciation of assets	2018-12-31	$437
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$176,104
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$189,694
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$184,589
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$248,735
Value of total assets at end of year	2018-12-31	$1,209,955
Value of total assets at beginning of year	2018-12-31	$1,223,545
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$5,105
Total interest from all sources	2018-12-31	$733
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$100,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$189,870
Participant contributions at end of year	2018-12-31	$12,209
Participant contributions at beginning of year	2018-12-31	$6,219
Participant contributions at end of year	2018-12-31	$75
Participant contributions at beginning of year	2018-12-31	$25
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$9,153
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-13,590
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$1,209,955
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$1,223,545
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Investment advisory and management fees	2018-12-31	$5,105
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$996,114
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$959,994
Value of interest in pooled separate accounts at end of year	2018-12-31	$151,845
Value of interest in pooled separate accounts at beginning of year	2018-12-31	$207,307
Interest on participant loans	2018-12-31	$733
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-73,801
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$49,712
Employer contributions (assets) at end of year	2018-12-31	$49,712
Employer contributions (assets) at beginning of year	2018-12-31	$50,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$184,589
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2018-12-31	450250958
2017 : EXCELSIOR WELLNESS 403(B) PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$388,145
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$126,998
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$120,455
Expenses. Certain deemed distributions of participant loans	2017-12-31	$299
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$219,249
Value of total assets at end of year	2017-12-31	$1,223,545
Value of total assets at beginning of year	2017-12-31	$962,398
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$6,244
Total interest from all sources	2017-12-31	$322
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$100,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$142,116
Participant contributions at end of year	2017-12-31	$6,219
Participant contributions at beginning of year	2017-12-31	$7,119
Participant contributions at end of year	2017-12-31	$25
Participant contributions at beginning of year	2017-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$27,133
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$261,147
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$1,223,545
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$962,398
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Investment advisory and management fees	2017-12-31	$6,244
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$959,994
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$912,412
Value of interest in pooled separate accounts at end of year	2017-12-31	$207,307
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$0
Interest on participant loans	2017-12-31	$322
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$168,574
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$50,000
Employer contributions (assets) at end of year	2017-12-31	$50,000
Employer contributions (assets) at beginning of year	2017-12-31	$42,867
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$120,455
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2017-12-31	450250958
2016 : EXCELSIOR WELLNESS 403(B) PLAN 2016 401k financial data
Total income from all sources	2016-12-31	$222,351
Expenses. Total of all expenses incurred	2016-12-31	$167,356
Benefits paid (including direct rollovers)	2016-12-31	$163,866
Total plan assets at end of year	2016-12-31	$962,398
Total plan assets at beginning of year	2016-12-31	$907,403
Value of fidelity bond covering the plan	2016-12-31	$100,000
Total contributions received or receivable from participants	2016-12-31	$110,099
Contributions received from other sources (not participants or employers)	2016-12-31	$6,675
Other income received	2016-12-31	$62,710
Net income (gross income less expenses)	2016-12-31	$54,995
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$962,398
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$907,403
Assets. Value of participant loans	2016-12-31	$7,119
Total contributions received or receivable from employer(s)	2016-12-31	$42,867
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$3,490
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0

Form 5500 Responses for EXCELSIOR WELLNESS 403(B) PLAN

2022: EXCELSIOR WELLNESS 403(B) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	Yes
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: EXCELSIOR WELLNESS 403(B) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: EXCELSIOR WELLNESS 403(B) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: EXCELSIOR WELLNESS 403(B) PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: EXCELSIOR WELLNESS 403(B) PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: EXCELSIOR WELLNESS 403(B) PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: EXCELSIOR WELLNESS 403(B) PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

1356055410

Policy instance

Insurance contract or identification number	1356055410
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,027
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,027
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	CONTRACT COMMISSIONS
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

1356055410

Policy instance

Insurance contract or identification number	1356055410
Number of Individuals Covered	3
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,089
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,089
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	CONTRACT COMMISSIONS
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

1356055410

Policy instance

Insurance contract or identification number	1356055410
Number of Individuals Covered	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $805
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $805
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	CONTRACT COMMISSIONS
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

1356055410

Policy instance

Insurance contract or identification number	1356055410
Number of Individuals Covered	3
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $824
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	824
Additional information about fees paid to insurance broker	CONTRACT COMMISSIONS
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

1356055410

Policy instance

Insurance contract or identification number	1356055410
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $885
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	885
Additional information about fees paid to insurance broker	CONTRACT COMMISSIONS
Insurance broker organization code?	3

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

1356055410

Policy instance

Insurance contract or identification number	1356055410
Number of Individuals Covered	4
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $793
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $793
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	CONTRACT COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CETERA ADVISOR NETWORKS LLC

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

VC4673

Policy instance

Insurance contract or identification number	VC4673
Number of Individuals Covered	1
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	CASH COMMISSION
Insurance broker organization code?	3
Insurance broker name	GREER KARLA

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Company Name:	EXCELSIOR WELLNESS
Employer identification number (EIN):	911189908
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	1982-10-01
Company Identification Number:	601138592
Legal Registered Office Address:	601 W MAIN AVE STE 1400 SPOKANE United States of America (USA) 992010635